CONSENT FOR VOLUNTARY INPATIENT TREATMENT

NAME OF PATIENT LAST FIRST MIDDLE AGE SEX

NAME OF COUNTY PROGRAM NAME OF BASE SERVICE UNIT BASE SERVICE UNIT NUMBER

NAME OF FACILITY ADMISSIONS DATE ADMISSIONS NUMBER

INSTRUCTIONS
BEFORE SIGNING THIS FORM, YOUR TREATMENT SHOULD BE EXPLAINED TO YOU AND YOU MUST BE
GIVEN A COPY OF THE PATIENT’S BILL OF RIGHTS. THE REPORT OF YOUR INITIAL EVALUATION AND
THE PROPOSED TREATMENT PLAN MUST BE COMPLETED AND SIGNED BY YOU AND THE PHYSICIAN.

VOLUNTARY CONSENT TO INPATIENT TREATMENT

For the above-named person who is: £ an adult 18 years of age or older or

£ a person who is at least 14 years

of age and not yet 18 years old

I consent to the treatment which has been explained to me including the types of medication, examination procedures and
the types of restrictions which are applicable; and

I understand that in order to leave before I am discharged, I must give hours advance notice in writing to
(UP TO 72)
those in charge of my treatment; and

I confirm that my rights and responsibilities while a patient in this hospital have been explained to me.

SIGNATURE OF PATIENT DATE OF SIGNATURE

For the above-named person who is: £ under 14 years of age

I consent to the treatment of my child or ward which has been explained to me including the types of medication,
examination procedures and the types of restrictions which are applicable; and

I understand that in order to take my child or ward out of the hospital before he or she is discharged, I must give
(UP TO 72)
hours advance notice in writing to those in charge of the patient’s treatment; and

I confirm that the rights and responsibilities for myself and my child or ward while a patient in this hospital have been
explained to me.

SIGNATURE OF: DATE OF SIGNATURE

£ PARENT OR

£ GUARDIAN

PRINT NAME OF PERSON SIGNING ABOVE

PAGE 1 of 2 MH 781 5/14

 INITIAL EVALUATION AND TREATMENT PLAN

INITIAL FINDINGS:

DESCRIPTION OF PROPOSED TREATMENT PLAN:

DESCRIPTION OF PROPOSED RESTRICTIONS AND RESTRAINTS:

SIGNATURE OF PHYSICIAN/DATE SIGNATURE OF CLIENT/PARENT/OR GUARDIAN/DATE

Any person who knowingly provides any false information when he/she completes this form may be subject to prosecution.

PAGE 2 of 2 MH 781 5/14